Page 1 of 5 OPPOSF29.0318

Request for Change of Beneficiary / Signature / Ownership / Trustee 更改受益人 / 簽名 / 持有人 / 信託人申請表

AIA International Limited (Incorporated in Bermuda with limited liability)

Policy Number 保單號碼 Name of Insured 受保人姓名 Name of Owner 持有人姓名

Agent / Broker Name 營業員 / 經紀姓名 Agent / Broker Code 營業員 / 經紀號碼 Area / Agency / Broker Code 區域 / 營業員 / 經紀組別編號

Agent / Broker Tel. No 營業員 / 經紀聯絡電話

TR Membership Number (for Brokers only) 營業代表會員號碼 (僅供經紀使用) PIBA CIB ANG

IMPORTANT NOTES 重要資料

I / We understand and agree that: 本人 / 我們明白及同意:

1) This request is NOT valid until (a) it is recorded as received by AIA International Limited (the "Company") during the life time of BOTH the Insured and the Owner of the above policy (the "Policy") and (b) it is finally confirmed and accepted by the Company by way of Endorsement or letter. 此申請表需於(a)上述保單(即「保單」)之受保人及持有人生存期間獲友邦保險(國際)有限公司(即「本公司」)收到並存檔及(b)最終經本公司以批註或信函確應及接納方為有效。

2) This form and the Endorsement (if any) will attach and form part of the Policy after it is accepted and approved by the Company. 當此申請表經本公司接納及批准後，此申請表及批註(如有)將附於保單契約內，且構成保單契約之一部分。

3) Receipt of this form by AIA Representative or your broker does not constitute receipt by the Company. The final decision on the validity of this form rests with the Company. 友邦業務代表或您的經紀收到此申請表並不代表本公司亦已收到，本公司對此申請表的有效性擁有最終決定權。

4) The Company has the right to update this form from time to time and to accept or to reject the form if the Company's requirements are not fulfilled. 本公司有權隨時更新此申請表 ，並接受或拒絕未符合本公司要求的申請表。

5) This form should be signed by the Owner / Trustee in the presence of a witness under the section of Declaration and Authorization. Insured / Owner / Trustee / Assignee‘ssignature, whenever applicable, must correspond with the Company’s latest available record. 持有人 / 信託人必須在見證人的作證下簽署此申請表的「聲明及授權」部分，受保人 / 持有人 / 信託人 / 受讓人(如適用)的簽名必須與本公司的最近存檔紀錄相符。

6) Any amendments in this form must be countersigned by the Owner / Trustee / Assignee in full signature.持有人 / 信託人 / 受讓人必須於此申請表內任何曾修改的地方簽署確實。

7) This Request is made subject to the terms and conditions of the Policy, and shall not result in a change / modification in any provision of the Policy, except as expressly provided for in the Policy and in any Endorsement. 此項申請受保單條款和條件所約束，且不會導致任何保單條款之更改 / 修改，除非該等更改 / 修改已於保單契約內及於任何保單批註內另有清楚列明。

8) There may be tax and / or other implications as a result of transferring ownership and / or change of beneficiary / trustee. The proposed New Owner / Trustee is asked to carefully study the terms and conditions of the Policy, and before signifying his / her consent to become the New Owner / Trustee of the Policy, he / she should first get a comprehension of what the rights and obligations would be conferred upon him / her. The proposed New Owner / Trustee is asked to make his / her own assessment on the ability to meet the premium and levy (Hong Kong policies) payment obligations. Please consult your own independent legal and / or tax advisors prior to making any request. Upon confirmation and recorded by the Company that the New Owner becomes the owner of the Policy, the New Owner shall assume all the obligations (which includes but without limitation, in respect of Hong Kong policies, the obligation to pay and settle all outstanding and future levy payable to the Insurance Authority) and are bound by and subject to the terms and conditions of the Policy. 此持有人 / 信託人之轉換，有可能涉及稅務及 / 或其他影響。新持有人 / 新信託人於簽署此項申請和同意作為新持有人 / 新信託人前，須仔細閱讀保單內之條款和條件，並清楚明白其授予之權利與責任。新持有人 / 新信託人須自行評估履行保單支付保費與保費徵費（香港保單適用）責任之能力。請閣下在作出任何申請前自行諮詢獨立法律 /稅務顧問。轉換持有人申請一旦被貴公司確認及記錄，新持有人需承擔所有受保單條款約束的責任（就香港保單而言，包括但不限於向保監局繳付所有逾期及未來應繳保費徵費），及受保單條款和條件約束。

9) Any Request for Change of Ownership / Trustee does not change the beneficiary or the mode of payment under the Policy. 申請更改保單持有人 / 信託人不會更改此保單之受益人及付款形式。

10) The current Owner warrants that the change of ownership is not subject to any prior agreement, contractual obligations, legal proceedings and / or orders by the Court / tribunal,which may restrict, limit or otherwise prohibit such change of ownership as contemplated. If any such restriction exists, the current Owner must produce the Company proper written consent from such person(s) together with the request. The current Owner expressly acknowledges and agrees that in the event of any obligations become known subsequent to the change of ownership being made, which if then made known to the Company, would have caused the Company not to process any Request for Change of Ownership on the Policy (or not to change ownership without the consent of a party other than the current Owner), the change of ownership will become immediately void and the current Owner shall indemnify and hold the Company harmless from any and all losses, damage, liabilities, proceedings, claims, demands and expenses arising out of and in connection with such Request of Change of Ownership. 現時持有人保證更改保單持有人之申請不受約束於事先協定、合約義務、法律訴訟及 / 或法院指令而限制或禁止更改保單持有人。現時持有人確認及同意倘因作出更改保單持有人後才發現的責任,以致貴公司不接納更改保單持有人之申請﹝或轉換持有人必須先取得非現時持有人之第三者同意﹞，更改保單持有人的申請將即時失效。及如貴公司因此更改而引致有任何損失、損害、 法律責任、訴訟、索償、要求及開支，現時保單持有人同意對貴公司作出彌償並保證貴公司不受損害。

11) The Company and its affiliates (“the Group”) are subject to, or have agreed to, comply with certain legal, regulatory and / or other requirements (the “Reporting Requirements”). As such, I / We provide our express consent that the Company shall have the right to provide such personal data and information to any governmental authorities, regulatory bodies and / or any other person(s) in respect of the Reporting Requirements. I / We understand that such disclosures may involve the cross border transfer of personal data outside the jurisdiction and that such disclosures may be with respect to i) the personal data of the Owner, the Contingent Owner, the Insured, and the Beneficiaries (“the Parties”), or any of them; ii) any information relating to this Policy; and iii) any information relating to any other policies held by the Parties or any of them. I / We understand that the Company will not be able to sell any insurance product to me / us and provide any service if I / we refuse to give the said express consent. 貴公司有權, 就如需要並在法律許可的範圍內，提供有關本人 / 我們的個人資料和其他有關持有人及 / 或新保單持有人及 / 或第二保單持有人持有之保單或投資資料予政府部門、監管機構、法院、法庭、行政委員會及 / 或執法機構（包括本地及海外）。貴公司也會就上述政府部門、監管機構、法院、法庭、行政委員會及 / 或執法機構所提出之任何問題及 / 或查詢作出回答，及在適當的情況下，會主動提供報告，以符合有關法律，法規和守則 / 行為。

12) A person who is not a party to this Policy (including but not limited to the Insured or the Beneficiary) has no right to enforce any of the terms of this Policy. 非保單合約一方（包括但不限於受保人及受益人）沒有權利執行任何保單條款。

O2722083

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Policy Number 保單號碼

Please tick the appropriate box 請在適當的空格內劃上“X” 號Part A 甲部 Change of Ownership / Trustee 更換持有人 / 信託人

Name of New Owner / Trustee 新持有人 / 信託人姓名:

Relationship to Insured 與受保人關係:

Sex 性別

ID / Passport No. 身分證 / 護照號碼:

Date of birth 出生日期: MM 月

----- DD 日

----- YYYY 年

Nationality 國籍:

For Juvenile Policy 兒童保單

With PB / PBCI rider* 保留付款人 / 危疾付款人附加契約* Yes 保留 No 不保留

Please state the intended purpose(s) for change of ownership to the new owner# 請述明更改保單持有人至新持有人之目的#:

Wealth Planning 財富規劃

Education Savings 教育儲備

Investment Management 投資管理

Income Protection 入息保障

Retirement Planning 退休計劃

Others, please specify 其他，請詳述:__________________________________________________________

New Owner / Trustee Occupation# 新持有人 / 信託人職業#:

Name of Employer 僱主名稱: ___________________________________________________________________________________________________________________________________

Business Address 辦事處地址: __________________________________________________________________________________________________________________________________

Occupation Title and Daily Duties 職位及日常職務: _______________________________________________________________________________________________________________

Nature of Business 公司業務性質: _______________________________________________________________________________________________________________________________

New Owner / Trustee’s Country / Jurisdiction of Tax Residence* 新持有人 / 信託人稅務居住國家 / 司法管轄區*:

You must provide the following information 你必須填寫以下資料: ☐ Tax resident of Hong Kong only 唯一稅務居住地為香港 ☐ Tax resident of Macau only 唯一稅務居住地為澳門

Country / Jurisdiction of tax residence 稅務居住國家 / 司法管轄區

Tax Identification Number (TIN) 稅務編號

If no TIN available, please enter Reason (A, B or C) 如未能提供稅務編號,請註明原因 (A, B 或 C)

If you selected Reason B, please explain why you are unable to obtain a TIN 倘若閣下敷擇原因 B,請在下列說明為何閣下未能取得稅務編號

1

2

3

Reason A – The country / jurisdiction where the new owner / trustee is resident does not issue TINs to its residents 原因 A - 新持有人 / 信託人所屬之國家 /司法管轄區沒有為其居民設立稅務編號 Reason B – The new owner / trustee is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the above table if you have selected this reason) 原因 B - 新持有人 / 信託人未能獲得稅務編號或有同等功能的編號(若選擇本原因,請於上表說明為何閣下未能取得稅務編號) Reason C – No TIN is required (Note: Only select this reason if the domestic law of the relevant jurisdiction does not require the collection of the TIN issued by such jurisdiction) 原因 C - 不需要稅務編號(備註：倘若閣下所屬之司法管轄區的相關本地法律並不需要收集稅務編號,方可選擇這個原因)

Important Note 注意事項: The Company is required by the laws to conduct due diligence on the new owner / trustee with respect to his / her / their tax residence, collect the required information and furnish a return to the governmental authorities. If there is any uncertainty about tax residency status, it is suggested that the new owner / trustee shall disclose the information in the above table and consult also your own tax advisor. 本公司是根據法律要求就新持有人 / 信託人之稅務居住地進行盡職調查，並收集所需資料及提供給政府機關。如新持有人 / 信託人對稅務居住地有任何疑問，請於上述

表格內表述並徵詢你的稅務顧問。

Note 注意:1. * Please complete Payor's Health Certificate. Otherwise, the attached PB or PBCI rider will be deleted. 如須保留付款人附加契約或危疾付款人附加契約，請提交

新持有人之健康證明書。否則，該附加契約將會被取消。2. If US Citizen, please submit Form W-9. 如屬美藉人士，請提交W-9表格。3. For insured under age 18, please also complete the column for designating a new contingent owner / trustee if the new owner / trustee and the original owner /

trustee are the same person.如受保人未滿18歲，而新持有人 / 信託人和原有的第二持有人 / 信託人是同一人，請填寫指定新的第二持有人 / 信託人。4. Please submit copy of ID / passport of the New Owner / Trustee. For Macau issued policy, please also submit residential and permanent address proof

issued within 3 months. In the case of new owner is a corporate, please submit company documents pursuant to the Anti-Money Laundering and Counter-Terrorist Financing (Finance Institutions) Ordinance. Our Company reserves the right to ask for additional documents. 請遞交新持有人/信託人的身分證/護照副本。如為澳門繕發之保單, 請一併遞交最近三個月內之住宅及永久地址證明文件副本。倘以公司名義之新持有人，必須根據現行之「打擊洗錢及恐佈分子資金籌集(金融機構)條例」遞交所需文件。本公司保留權利索取其他文件。

* For new owner is a corporate , please complete “Self Certification Form – Entity” as required by the laws. If the entity is classified as passive NFE, please also complete “Self Certification Form – Controlling Person” for each identified controlling person.

* 倘以公司名義之新持有人，必須根據法律要求遞交「自我證明表格 - 實體」。如有關公司持有人之公司類別為被動非財務實體，每一位控權人必須填寫「自我證明表格- 控權人」。

# As required by the Anti-Money Laundering and Counter-Terrorist Financing (Financial Institutions) Ordinance and other applicable guidelines, customer due diligence on new owner or trustee upon change of ownership shall be completed to the satisfaction of the Company. Therefore, the Company reserves the right to determine the scope of such customer due diligence, and to request you for further clarification and additional documents if deemed necessary.# 本公司需要根據「打擊洗錢及恐佈分子資金籌集(金融機構)條例」及其他適用指引，就更改保單持有人對新持有人/信託人進行客戶盡職審查。因此，本公司保留權利決定該盡職審查之範圍，並要求作進一步闡述及索取其他文件。

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Policy Number 保單號碼

New Owner / Trustee Correspondence Address / Telephone Numbers / Email Address: 新持有人 / 信託人通訊地址 / 電話號碼 / 電郵地址: Please complete in English block letters. Post Office Box is not accepted as correspondence address. 請以英文正楷填寫。恕不接受郵政信箱作為通訊地址。

Flat / Room 室: Floor 樓數: Block 座數:

Country Email Address :

Building / Estate Name : 大廈 / 屋邨名稱No. & Name of Street / Lot No. : 街道名稱及號數 / 地段號數District: 地區 H.K 香港 / KLN 九龍 / N.T.新界 國家: 電郵地址

Telephone Number 電話號碼: Other Countries Telephone Number 其他國家電話號碼: Mobile Fixed Line Country Code Area Code

Hong Kong 香港 Mobile 手提: 手提 固網 國家號碼 地區號碼

Macau 澳門 Office 公司: ( ) – ( ) -- ______________________________

Home 住宅 : ( ) – ( ) -- ______________________________

U.S. Telephone Number 美國電話號碼: * The contact details of the original policyowner on the company record will be treated as those of the new policyowner if you leave this part blank.* 如閣下沒有填寫此欄，則新持有人的通訊資料將沿用原有持有人於公司紀錄上的資料。

Residential Address and Permanent Address will be changed as Correspondence Address stated on this form, otherwise please specify below. 住宅地址及永久地址將更改至此表格上填寫之通訊地址，否則請於下方列明。

Residential Address 住宅地址: ________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Permanent Address 永久地址: ________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

DIRECT PROMOTIONAL AND MARKETING MATERIALS (For New Owner / Trustee) I / We confirm that I / we have read and understood the AIA Personal Information Collection Statement (“AIA PIC”). I / We agree to the provision and use of my / our personal data for direct marketing purposes in accordance with the AIA PIC. I / We acknowledge and consent to the transfer of my / our personal data outside of Hong Kong (for policies issued in Hong Kong) or Macau (for policies issued in Macau), as the case may be, for direct marketing purposes and to the types of transferee as set out in the AIA PIC. [ ] Please tick the box on the left if you do not agree with the provision, use and transfer of your personal data for direct marketing purposes in accordance with the AIA PIC.

宣傳及市場推廣資料 (新持有人 / 信託人適用) 本人 / 我們現確定本人 / 我們已閱讀及明白AIA個人資料收集聲明(「AIA個人資料收集聲明」)。本人 / 我們同意根據AIA個人資料收集聲明,提供本人 / 我們的個人資料用作直銷推廣用途。本人 / 我們確認及贊同把本人 / 我們的個人資料轉至香港(如保單在香港繕發)或澳門(如保單在澳門繕發)境外作直銷推廣用途，並把相關的個人資料轉移至AIA個人資料收集聲明中列明的資料承讓人。

[ ] 倘若不同意根據AIA個人資料收集聲明，提供、使用及轉移個人資料用作直銷推廣用途，請在左列 [ ] 一欄劃上✓。

Signature of New Owner / Trustee:

新持有人 / 信託人簽名:

By signing in this section, the New Owner / Trustee agrees to assume all the obligations and be bound by the terms and conditions of the Policy which currently bind the Owner / Trustee of the Policy. 就簽署此部分，新持有人 / 信託人同意需承擔所有受保單條款約束的責任及受保單條款和條件約束，此約束與持有人 / 信託人相同。

there is change to source of wealth and source of fund since policy inception or last ownership/trustee change.由此保單繕發或由上次更改持有人/信託人以來，財富來源和資金來源已改變。

(Our Company reserves the right to ask for additional documents and income/asset proof on new owner/trustee.) (本公司保留權利要求新持有人/信託人遞交額外的文件及收入/資產證明。)

Source of Wealth/Source of Fund Declaration 財富來源/資金來源聲明

We, the original and new owner / trustee of the policy, declare that 我們，為原保單及新保單持有人/信託人，在此聲明:

there is NO change to source of wealth and source of fund since policy inception or last ownership/trustee change.由此保單繕發或由上次更改持有人/信託人以來，財富來源和資金來源沒有改變。

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Policy Number 保單號碼

Part C 丙部 Change Of Beneficiary (Not applicable to juvenile policies currently issued under the Trust Provisions) 更換受益人(不適用現在受信託條文約束的兒童保單)

Unless prohibited by any assignment or any other lawful act / restriction, the Owner hereby reserves the right, during the lifetime of the Proposed Insured and without the consent of any beneficiary or trustee, by written notice to the Company in its prescribed form to :(a) Change and revoke the appointment of any beneficiary and substitute his / her own name or any other name therefor; and (b) Appoint a trustee to receive the proceeds for the beneficiary, and change or revoke any prior trustee designation or appointment. The Company is not responsible for the validity of any appointment or revocation and for any subsequent written notice of a change of beneficiary received by it pending the issue of endorsement.對於任何委任或撤銷的有效性以及其後本公司收訖而正待簽發批註更改任何受益人的書面通知，本公司不負任何責任。除因任何轉讓或任何其他合法

行事/ 限制而受到禁止外，持有人可保留權利於準受保人在生期間及無須獲得任何受益人或信託人之同意，以本公司的指定表格向我們遞交書面通知，

要求:(甲)更改及撤銷對任何受益人的委任，並以其個人姓名或任何其他姓名取代；及(乙)委任信託人代受益人接收賠償，以及更換已指派之信託人或撤

銷該項指派。

Change of Signature 更換簽名

New Signature of Owner / Trustee 持有人 / 信託人之新簽名 New Signature of insured (if different from the Owner) 受保人之新簽名(倘非持有人)

Declaration & Authorization 聲明及授權 I, Owner / Trustee of the Policy, request that this Policy be changed according to the above particulars. I understand and agree that a copy of this request will be attached to and form a part of the said Policy. When the request relates to change of beneficiary in respect of this Policy, I confirm that my previously designated beneficiary or beneficiaries (other than the estate of the Insured) is / are fully aware of and if consent is required, has / have consented to this request. 本人為保單的持有人 / 信託人，在此要求保單按照上述細則更改。本人明白及同意申請表之副本將附於本保單契約內，且構成保單契約之一部份。如更換保單的受益人，本人確認本人之前為此保單所指定的受益人(受保人的遺產除外)均完全知悉，及如需要獲取其同意，已同意此申請表上的內容。

PERSONAL DATA COLLECTION AND USE I / We confirm that I / we have read and understood the AIA Personal Information Collection Statement ("AIA PIC"). I / We declare and agree that any personal data and other information relating to me / us or my / our policy(ies) or investments contained in this application or collected, obtained, compiled or held by the Company by any means from time to time may be collected and utilized in accordance with the AIA PIC. I / We acknowledge and consent to the transfer of my / our personal data outside of Hong Kong (for policies issued in Hong Kong) or Macau (for policies issued in Macau), as the case may be, for the purposes and to the types of transferee as set out in the AIA PIC. The updated version of AIA PIC is available for download from its website: www.aia.com.hk, and is made available upon request. 個人資料收集及使用

本人 / 我們確認本人 / 我們已閱讀及明白AIA個人資料收集聲明(「AIA個人資料收集聲明」)。本人 / 我們聲明及同意在本申請所載或貴公司不時以任何方法收集所得、編製或持有的任何個人資料及關於本人 / 我們或本人 / 我們的保單或投資的其他資料，可根據 AIA 個人資料收集聲明收集及使用。本人 / 我們知悉及同意就 AIA 個人資料收集聲明所述目的視乎情况轉讓本人 / 我們的個人資料至香港(如保單在香港繕發)或澳門(如保單在澳門繕發)境外予AIA個人資料收集聲明所載的資料承讓人。AIA 個人資料收集聲明的最新版本可於以下網址下載：www.aia.com.hk，及可向貴公司索取。

Beneficiary's Name受益人姓名

Relationship to insured 與受保人之關係

ID / Passport No.身分證/護照號碼

Share(%)百分比

Note注意: 1. If more than one beneficiary is designated, all policy proceeds will be paid to the beneficiaries according to the order of payment (if any) and share(s) specified or in

equal shares (where the beneficiaries rank equally and their respective shares are not specified). 如受益人超過一人，保單內的利益將按照在此列明的付款次序(如有)及比例分配給各受益人，或保單內的利益將平均分配給各受益人(如各受益人的分配比例相同或在此沒有列明分配比例)。

2. The above change of beneficiary designation shall be effective only while the relevant Policy is in force and to the extent permitted by law. 在上述保單仍然生效及法律容許的情況下，以上更改受益人的指示才告生效。

Part B 乙部 Change of Contingent Owner / Contingent Trustee (Not applicable to policies with Insured at age 18 or above) 更換第二持有人/信託人(不適用於受保人已年滿 18 歲或以上的保單)

Name of Contingent Owner / Contingent Trustee 第二持有人 / 信託人姓名

Relationship to Insured與受保人關係

Date of Birth (MM-DD-YYYY) 出生日期 (月-日-年)

ID / Passport No. 身分證/護照號碼

Part D 丁部

Date of Birth (MM-DD-YYYY) 出生日期 (月-日-年)

Sex 性別

Sex性別

Page 5 of 5 OPPOSF29.0318

Policy Number 保單號碼

By signing below, I / we represent that I am / we are not a U.S. person for purposes of U.S. federal income tax and that I am / we are not acting for, or on behalf of, a U.S. person. If the Owner is a body corporate, I / We represent that the Owner does not have any beneficial owner(s) with a 10% or more direct or indirect interest in the corporate who is a U.S. citizen, resident or U.S. Entity. I / We understand that the Company, believing this statement to be true, will rely on it and act on it. In the event this statement is incorrect / false, the Company reserves the right and shall be entitled to cancel the policy. Any policy issued may accordingly be considered void in which case the Company shall notify me / us and repay any premiums and levy (for Hong Kong policies)less reasonable charges and policy withdrawals / loans. Note: A false statement or misrepresentation of tax status by a U.S. person could lead to penalties under U.S. law. If your tax status changes and you become a U.S. citizen or resident, you must notify us within 30 days. (This Clause is not applicable to U.S. citizens or residents, who must complete IRS Form W- 9.) 於下方簽署作實，本人 / 我們聲明，就美國聯邦薪俸稅之有關事項而言，本人 / 我們並非美國人，及並不代表美國人行事。如持有人為

法人，本人 / 我們聲明股東中沒有美國公民 / 美國居民 / 美國機構直接或間接持有大於 10%的股權。 本人 / 我們明白貴公司相信此陳述是

真實的，並以此為依據及代為行事。倘若此陳述是不正確 / 虛假的，貴公司保留權利，並有權取消保單。任何依據此陳述而繕發的保單可

視作無效。在這情況下，貴公司將通知我 / 我們償還扣除合理的費用及保單提款 / 貸款後的保費與保費徵費（香港保單適用 )。 備注﹕根據美國法律，任何美國人就其稅務狀況有虛假或失實陳述，將會受到刑罰。若閣下的稅務狀況有更改，並且成為美國公民或居

民，請於三十日內通知本公司。(美國公民或居民必須填寫 IRS 之 W-9 表格，而以上之有關條款並不適用。) I / We acknowledge and irrevocably agree that the information contained in this form and information regarding the Applicant(s) and any Reportable Account(s)* may be provided to the tax authorities of the country / jurisdiction in which this account(s) is / are maintained and exchanged with tax authorities of another country / jurisdiction or countries / jurisdictions in which the Applicant(s) may be tax resident pursuant to intergovernmental agreements to exchange financial account information. *“Reportable Account” has the meanings ascribed to it under the “Common Standard on Reporting and Due Diligence for Financial Account Information” promulgated by the Organisation for Economic Cooperation and Development. For individual applicant(s) - I / We certify that I am / we are the Applicant(s) (or am authorized to sign for the Applicant(s)) of all the account(s) to which this form relates. For corporate applicant(s) - I certify that I am authorized to sign for the Applicant in respect of all the account(s) to which this form relates − I / We declare that all statements made in this declaration are, to the best of my / our knowledge and belief, correct and complete. − I / We undertake to advise the Company within 30 days of any change in circumstances which affects the tax residency status of the party / parties identified as Applicant of this form or causes the information contained herein to become incorrect or incomplete, and to provide the Company with a suitably updated self-certification and Declaration within 30 days of such change in circumstances. − I / We agree to indemnify the Company against any loss, claim and action in connection with any false, misleading or incomplete information of my / our nationality, residence and / or tax status. 本人 / 我們知悉並完全同意這表格內,所有資料及有關申請人之個人資料,和任何須申報帳戶*,將有可能提供予管理該帳戶的國家 / 司法管轄區之稅務機關,及轉交予其他國家 / 司法管轄區之稅務機關或申請人所屬之國家 / 司法管轄區為根據跨政府協議所訂之財務帳戶資料交換要求的國家 / 司法管轄區。

*“須申報帳戶”之定義請參考經濟合作與發展組織頒佈的“共同申報準則及財務帳戶資料之盡職調查” 由個人作申請人 - 本人 / 我們在此聲明,本人 / 我們是本申請書相關之全部帳戶的申請人(或獲申請人授權簽署)。由公司作申請人 - 本人在此聲明,本人是獲申請人授權簽署本申請書相關的全部帳戶。

− 本人 / 我們聲明一切在這份聲明之條款是基於本人 / 我們的據知及所信,並且是正確及完整的。

− 本人 / 我們承諾,如有任何改動會影響認定為申請人之一方 / 多方之稅務居民狀況內容,或導致其所載資料失實或不完整,本人 / 我們將於有關改動發生後30日內通知貴公司,並在該變動發生後30日內,向貴公司提交最新的自我證明書。− 本人 / 我們同意賠償貴公司就本人 / 我們的國籍、居住及 / 或稅務狀況有關資料之虛報、誤導或不完整所導致的任何損失,索償及訴訟。

PLEASE SIGN & RETURN IMMEDIATELY BUT NO LATER THAN 14 DAYS 請簽署後即時但不數於 14 天內遞交

PLEASE DO NOT SIGN ON BLANK FORM 請勿在空白表格上簽署

MM月 / DD日 / YYYY年 Signature of Insured ( if different from the Owner)受保人簽名(倘非持有人)

On 於 Signature of Witness #

見證人簽名

On 於

Signature of Owner 持有人簽名

On 於

Signature of Assignee (if applicable)

受讓人簽名(如適用)

On 於

First 4 characters of HK / Macau ID Card Number of Witness: 見證人之首四個位香港 / 澳門身份證號碼:___ ___ ___ ___ XXXX

OR First 5 characters of Passport No.: 或護照首五個位之號碼: ___ ___ ___ ___ ___

Contact Phone No. of Witness 見證人之聯絡電話號碼: _______________________

MM月 / DD日 / YYYY年

MM月 / DD日 / YYYY年

MM月 / DD日 / YYYY年

Name of Witness 見證人名姓名:

(English / Chinese name in Full) (英文 / 中文全名)

# Note: This form MUST be signed by you in the presence of an adult witness. For beneficiary changes, the witness cannot be a named beneficiary or an existing beneficiary. For owner / trustee changes, the witness cannot be a proposed new owner / trustee. The above personal particulars of the witness will not be used by the Company for any marketing purposes, including any data-matching or direct marketing activities. Such data will only be used for the purpose of processing this application form, in particular, for the verification and confirmation of the identity(ies) of the signatory(ies) of this form.

# 注意:此申請表必須由閣下在成年見證人的作證下簽署。如申請事項為更改受益人，見證人不能夠是被提名的受益人或現有的受益人；如申請事項為更改持有人 / 信託人，見證人則不能夠是被提名的新持有人 / 信託人。本公司不會將以上見證人的個人資料用於任何營銷目的上，包括資料配對或直接促銷，見證人之個人資料只會用於處理本申請表，特別為確實本申請表簽署人的身分之用。